Ruptures, repairs, and reflections: contributions of Jeremy D. Safran

Jeremy D. Safran’s contributions to our understanding of the complexities of the therapeutic relationship, and its role in the process of patient change in psychotherapy, have been profound. In this paper, we briefly summarize the evolution of his thinking about the alliance and highlight how his ambivalence about this construct contributed to his seminal work delineating rupture resolution models, defined as negotiated intersubjective processes between patient and therapist that are the very essence of the therapeutic process for some patients. Responding to strains in the alliance throughout the rupture resolution process is critical and is an aspect of the treatment model that trainees find most challenging. A clinical example is included to illustrate how Jeremy’s attempts at metacommunicating about his experience with a frustrated patient initiated a productive shift in the process that also contributed to additional ruptures, requiring a simultaneous focus on the strained alliance

Resolving Alliance Ruptures from an Attachment-Informed Perspective.

In this article, we examine how the different attachment patterns enable or hinder the resolution of ruptures in the therapeutic alliance. We try to show that secure and insecure patients alike may experience ruptures in the therapeutic alliance, but that their ability to participate in resolving such ruptures differ markedly. Recent findings with the Patient Attachment Coding System (PACS) show that attachment classifications manifest in psychotherapy as distinct ways of communicating about present internal experience. Secure patients disclose their present experience openly and invite attunement from the therapist, while insecure patients either minimize their contributions to the dialogue (avoidant) or the contributions of the therapist (preoccupied). Using examples from session transcripts, we demonstrate how secure patients are particularly responsive to resolution strategies that focus on here-and-now experience, while insecure patients' characteristic ways of communicating pose significant challenges to the resolution process

Alliance ruptures and resolutions in short-term psychoanalytic psychotherapy for adolescent depression: an empirical case study

Most research on alliance rupture-repair processes in psychotherapy has been carried out with adults and little is known about the alliance dynamics with adolescents, especially in psychodynamic treatments. OBJECTIVE: This study aimed to better understand the process of alliance rupture–resolution and its role in a good-outcome case of a depressed adolescent treated with short-term psychoanalytic-psychotherapy (STPP). METHOD: A longitudinal, mixed-methods empirical single-case approach was employed. Multiple sources of information (questionnaires, interviews, sessions recordings) from various perspectives (adolescent, therapist, observer) were assembled and analysed. RESULTS: The different sources of evidence converged and showed that, despite the presence of frequent alliance ruptures, patient and therapist managed to resolve these and develop a good and collaborative relationship. Both patient and therapist regarded the evolution in their relationship as the treatment factor mainly responsible for the positive changes experienced by the adolescent. Based on both theoretical and empirical data, a preliminary model of how to explore and repair alliance ruptures in STPP is presented. CONCLUSION: This study illustrates one way of applying an empirical, mixed-method approach to a single case. Its finding supports the idea that the process of repairing ruptures is an important mechanism of change. Strengths, limitations, and possible implications are discussed

Repairing alliance ruptures in psychodynamic psychotherapy with young people: The development of a rational-empirical model to support youth therapists

Alliance ruptures in youth psychotherapy can have a significant impact on treatment outcomes. However, there is currently limited guidance on how to effectively repair these ruptures with young people. This study aims to address this gap specifically in the context of psychodynamic psychotherapy with adolescents. The objectives of the study are (a) to understand the therapeutic interventions and attitudes that either facilitate or hinder the resolution of alliance ruptures and (b) to develop a model for repairing these ruptures within this particular treatment approach. To accomplish this, a task analysis of a previously developed rational model of resolving alliance ruptures was conducted using 16 sessions from short-term psychodynamic psychotherapy with depressed adolescents. The analysis supported some stages of the hypothesized rational model while revealing the need for revisions. As a result, the study developed a rational-empirical model that includes flexible strategies that therapists can use to repair alliance ruptures. This model emphasizes the significance of a collaborative, open, and empathetic approach to resolving ruptures. In contrast, rigid, defensive, or invalidating therapist attitudes can hinder the resolution process. The evidence-based model developed from the study can provide valuable guidance to psychodynamic psychotherapists working with young people, offering insights on how to approach ruptures and employ effective strategies to promote their resolution. (PsycInfo Database Record (c) 2023 APA, all rights reserved)

Impact of Optimized Breastfeeding on the Costs of Necrotizing Enterocolitis in Extremely Low Birthweight Infants

To estimate risk of NEC for ELBW infants as a function of preterm formula and maternal milk (MM) intake and calculate the impact of suboptimal feeding on NEC incidence and costs

Comparison of Brain Activity Correlating with Self-Report versus Narrative Attachment Measures During Conscious Appraisal of an Attachment Figure

Objectives: The Adult Attachment Interview (AAI) has been the gold standard of attachment assessment, but requires special training. The Relationship Scales Questionnaire (RSQ) is a widely-used self-report measure. We investigate how each correlates with brain activity during appraisal of subjects' mothers.Methods: 28 women were scored on the AAI, RSQ, and mood measures. During functional magnetic resonance imaging, subjects viewed their mothers in neutral-, valence-, and salience-rating conditions. We identified regions where contrasts in brain activity between appraisal and neutral viewing conditions correlated with each measure of attachment after covarying for mood. AAI and RSQ measures were then compared in terms of the extent to which regions of correlating brain activity overlapped with default mode network (DMN) versus executive frontal network (EFN) masks and cortical versus subcortical masks. Additionally, interactions with mood were examined.Results: Salience and valence processing associated with increased thalamo-striatal, posterior cingulate, and visual cortex activity. Salience processing decreased PFC activity, whereas valence processing increased left insula activity. Activity correlating with AAI vs. RSQ measures demonstrated significantly more DMN and subcortical involvement. Interactions with mood were observed in the middle temporal gyrus and precuneus for both measures.Conclusions: The AAI appears to disproportionately correlate with conscious appraisal associated activity in DMN and subcortical structures, while the RSQ appears to tap EFN structures more extensively. Thus, the AAI may assess more interoceptive, 'core-self'-related processes, while the RSQ captures higher-order cognitions involved in attachment. Shared interaction effects between mood and AAI and RSQ-measures may suggest that processes tapped by each belong to a common system